Julie’s Got You Covered

Beyond the Fine Print: Understanding What's Missing From Your Health Insurance

• Julie Sears • Episode 13

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Are There Any Exclusions Or Limitations In Your Insurance Policies? 

Feeling bewildered by the fine print in your health insurance policy? You're not alone. Julie Sears, founder of Integrity Health Insurance Advisors, pulls back the curtain on one of the most confusing aspects of health coverage: exclusions and limitations.

Understanding the distinction between ACA-compliant plans and private options becomes crucial when navigating exclusions. Only ACA plans guarantee coverage for pre-existing conditions without waiting periods, while private plans may offer more flexibility with certain trade-offs. Julie breaks down the difference between elective and medically necessary treatments with practical examples, helping listeners understand why insurance companies make the coverage decisions they do. Most importantly, she emphasizes the value of expert guidance in deciphering insurance terminology to avoid unexpected coverage gaps when you need care most.

Have questions about what your current or potential insurance plan actually covers? Book your free 30-minute consultation with Julie online or call to ensure you're getting the coverage you truly need.

To learn more about Integrity Health Insurance Advisors visit:
https://www.IntegrityHealthInsuranceAdvisors.com/
Integrity Health Insurance Advisors
469-348-4066

Speaker 1:

Welcome to Julie's Got you Covered, the podcast where Julie Sears, founder of Integrity Health Insurance Advisors, takes the fear out of finding the right health insurance. With seven plus years of experience, she's here to make finding the perfect coverage a breeze. Stay tuned for details on how you can snag a free 30-minute consultation.

Speaker 2:

tuned for details on how you can snag a free 30-minute consultation. It's crucial to understand the exclusions and limitations in any insurance policy to avoid unexpected surprises. Julie Sears breaks down common exclusions and how to navigate them so you can make the most of your health insurance. Welcome back everyone. I'm Sophia Yvette, co-host slash producer, back in the studio with Julie Sears. Julie, how has your day been?

Speaker 3:

Pretty good. It's nice and sunny out today.

Speaker 2:

Well, we're ready. Julie, Tell us, are there any exclusions or limitations in your insurance policies?

Speaker 3:

So, since I shop everything that's available in any given area that I'm licensed in, there can be a wide range of exclusions just depending on what we're looking at and what's available to whoever's enrolling at the time and whether they have a special enrollment. Private options are almost always going to have some types of exclusions. That's what makes them private and not Obamacare compliant. I do get a lot of questions about specific items that people are looking to have covered that aren't even covered on the ACA. One of the of course it's a heartbreaking one, but you know, something that people are looking for more and more is going to be fertility treatments and unfortunately, public and private options don't typically cover those. Usually they're going to be covered based on an employer plan and those are going to be just up to the employer. Those employers are going to customize those plans.

Speaker 3:

I got hit up by a mechanic shop. They're probably not going to offer a lot of fertility treatments because they're working with a lot of guys and that's not probably something that their men are worried about. Obviously they will have families that could be, but it helps keep the cost down if it's not a covered expense, because it can be very costly, but with private options. Oftentimes that same maternity coverage is not often covered, or mental health, because those are just a wide array of expenses that can be incurred during that. So every policy may not be the best fit. Sometimes you're going to have a large deductible that has to be met first, so it's not necessarily excluded, it just may be cost prohibitive. So those are things that I just help you know in that process of uncovering what you normally use your coverage for, what you're looking to do with that coverage, so that we make sure we get you the right fit.

Speaker 2:

And Julie, are there any ways around not having those coverages when needing help with fertility or mental health besides going to an employer?

Speaker 3:

The CA is going to be the best option if you're looking for that mental health coverage.

Speaker 3:

Those Obamacare plans do cover mental health.

Speaker 3:

Again we dig in to see which ones are going to be most cost effective because a lot of times it does go to a deductible and unfortunately we're moving in an area where a lot of mental health providers are not participating insurance because it's a pain to them to have those expenses and the trouble of having to file and follow up and get paid on those claims.

Speaker 3:

So oftentimes you might pick a plan and find out your provider doesn't take insurance anyway. So again, kind of in that discovery mode of helping someone out in their journey of finding their own insurance, part of what I do is look to see if your provider is in network, if they even accept insurance, so that if they don't let's find more cost savings in that premium If you're not going to be using the insurance for that service anyway. But really with the fertility there's really no ways around it. It's a costly expense that a lot of women and families are having to go through and typically employer plans are going to offer the best coverage and it's got to be pretty much a high level. Some small businesses really do try to incorporate as much of it as possible, but it's just going to be a case by case basis and unfortunately you might just end up with an employer who doesn't cover it.

Speaker 2:

So, julie, how can someone ensure they fully understand the limitations of their insurance policy?

Speaker 3:

ask for help. You know that's something that I don't mind doing for someone so that they really truly understand what they're getting in the event that they do need to use that worst case or that specialized thing that they're looking for. It can range from, you know, specialized hearing aids to eye surgery or something that you're just not thinking of on a normal day-to-day basis, but it could be a genetic thing that you're looking for that, if it crops up in the future, is that something that's going to be covered for me? And I know the ins and outs and I can read the insurance speak so I can help translate into our normal everyday terms and let you know if that thing that you're looking for whether it's something that you think might be basic it might not be basic for somebody else, because everybody's needs are different and what we normally use our coverage for can vary greatly from person to person, and we just want to make sure you've got the right thing in place.

Speaker 2:

And are there any situations where a pre-existing condition could be covered by?

Speaker 3:

insurance. The only way to ensure pre-existing is 100% covered would be with those ACA plans, those Affordable Care Act plans. They're not going to exclude anyone. Depending on what that pre-existing is and what it entails, there are some private plans that will be a good fit. Sometimes there's just some waiting periods that you have to get through, and that's what I'm here to help you navigate.

Speaker 2:

So, julie, what is the difference between elective and medically necessary treatments and insurance coverage?

Speaker 3:

So with elective it's something that is not going to be life-threatening or medically necessary for you to continue having a normal day-to-day life. Oftentimes the insurance is not going to cover it. At least you can utilize their pre-negotiated rates that they're contracted so that you'll at least have some cost savings there. But if the insurance deems that it is not medically necessary for you to have that normal day-to-day life, then oftentimes they're not going to cover or pay benefits because that's just not something in their plan.

Speaker 2:

Would be a situation where something like that would be covered. Something more like someone breaks their nose and needs a nose job, is that?

Speaker 3:

yes, types of things. Yeah, so that would be medically necessary to kind of make you whole again so that you know you don't have breathing problems down the line and end up with a bigger problem that ends up costing more money for them if it wasn't corrected properly. So then, yeah, you get your nose job. I wouldn't advocate for someone to you know, go break your nose so that you can get that bump fixed somewhere. Then it may cause more damage than good.

Speaker 2:

Definitely so, Julie. What should you do if you discover an exclusion in your policy that you weren't aware of?

Speaker 3:

Unfortunately, you're probably going to have to wait until that next open enrollment period so that you can make a change and find a better fit, so that we can get that stuff properly covered. That stuff properly covered in the event that it is something that you need done sooner than later, it may just be a cash expense that you're going to have to have if it's something that can't wait or that you don't want to wait on. I've had some clients that don't want to wait and end up just financing it and doing some care credit or whatever they need to do to get it taken care of Again, utilizing those negotiated rates that are through the insurance company anyway, so that at least they get a lower cost instead of just being uninsured.

Speaker 2:

Love it, Julie. We'll catch you in the next episode. Have a fantastic rest of your day.

Speaker 3:

You too.

Speaker 1:

Thanks for tuning in to. Julie's Got you Covered. Ready to say goodbye to insurance stress Head to IntegrityHealthInsuranceAdvisorscom or call 469-348-4066. That's 469-348-4066 to book your free 30-minute consultation With Julie. Health insurance doesn't have to be scary. She's got you covered.